Hello and welcome to this four-part webinar series on perinatal mental and substance use disorders. This webinar series is a result of the work conducted by a group of clinicians, researchers, and clinical researchers from across various disciplines in mental and behavioral health. Before starting the webinar, we would like to acknowledge that this product would not be possible without the partial funding from the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services, grant number NU38OT000288. In addition, we would like to stress that the contents provided herein are solely the responsibility of the authors and do not necessarily represent the official views of, nor an endorsement by, HHS, CDC, or the CDC Foundation. Similarly, the contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the American Psychiatric Association, the APA. We would like to draw your attention to terminologies used in the webinar series. Where possible, we have used inclusive language such as person or persons instead of woman or women. For example, we refer to pregnant persons instead of pregnant women. This has been done consistently throughout the webinar, except in instances where the research we cited specifically stated that there are inclusions of women only in their study population. Similarly, we use the inclusive term parental instead of maternal. In contrast, you will notice that we used the word breastfeeding throughout the webinar. This was done because the studies we reviewed talked about breastfeeding. However, we would like to acknowledge that However, we would like to acknowledge that chest feeding is a more inclusive term. Other terms of interest include antenatal or antepartum, which refers to before birth. Postnatal refers to after birth. Perinatal covers the pregnancy and postpartum period. Peripartum covers the period shortly before, during, and immediately after giving birth. Postpartum refers to the postnatal period up to one year following given birth. We also use the acronym PANPBH, and this is used to refer to psychiatrists and non-physician behavioral health when referring to the practitioners who participated in the focus groups and surveys associated with this initiative. So, why is this topic and webinar series important? Well, studies have shown that mental and substance use disorders are associated with poor obstetrical outcomes, as well as poor outcomes for a fetus or child. Despite these findings, the rate of psychiatric treatment in the perinatal population treatment in the perinatal population remained low. Furthermore, there is limited research on best practices for the treatment of perinatal mental and substance use disorders. Compounding the issue of low rate of treatment and limited research on best practices are the findings that there is inadequate training of psychiatrists and non-physician behavioral health practitioners in the United States. Understanding the factors that contribute to the inadequate training of psychiatrists and non-physician behavioral health practitioners is important for the field of perinatal mental health care. Osborne and colleagues in their 2015 survey of psychiatry residency training directors found that only 36% of directors believed that their residents required competencies in this area. These directors cited lack of time to teach a topic as the primary barrier. These observations, plus the anecdotal reports by persons with mental and substance use disorders of having their clinical care dropped by their behavioral health practitioners once they become pregnant, was the impetus behind the project that resulted in this webinar series. The project aimed to investigate if the anecdotal report was supported and to try to identify potential causes and consequences as well as strategies to address this issue. A number of methods were utilized to address the issue with the goal of developing a perinatal psychiatric toolkit, which includes this webinar series as well as to formulate educational and training recommendations. Methods used included separate focus groups and surveys of pregnant persons and psychiatrists and non-physician behavioral health practitioners and their trainees. Similar to the 2015 survey of psychiatry residency training director conducted by Osborne and colleagues, we surveyed program chairs and training directors of mental and behavioral health training programs. But in addition to psychiatrists, our sample included clinical psychology, clinical social work, clinical mental health counseling, and advanced nurse practitioner programs. In addition, we conducted literature review on various topics in the broad areas of epidemiology, etiology, and adverse outcomes, clinical management of perinatal mental and substance use disorders, perinatal mental and substance use disorders in vulnerable and underserved populations, and training gaps in perinatal mental health care. The results of the literature review formed the basis for this webinar series with supplemental information from the focus groups and, in some instances, the surveys conducted. The work was informed by an advisory panel of experts from across various disciplines in behavioral and mental health. This four-part webinar series aims to enhance your awareness and understanding of treatment and training gaps in perinatal mental and substance use disorders and their impact. The series highlights ways to address these gaps. The webinar series include Webinar 1, Epidemiology, Etiology, and Adverse Outcomes of Perinatal Mental and Substance Use Disorders, Webinar 2, which covers Clinical Management of Perinatal Mental and Substance Use Disorders, Webinar 3, which focuses on Vulnerable and Underserved Populations with Perinatal Mental and Substance Use Disorders, and the fourth webinar that covers Behavioral Health Education and Training in Perinatal Mental and Substance Use Disorders with a focus on gaps and recommendations. We hope you find each session and the full webinar series informative. Welcome to Part 3 of this webinar series on Perinatal Mental Health and Substance Use Disorders. Today, we're going to be focusing on Vulnerable and Underserved Populations. I am Louisa Olushoga, Staff Psychiatrist at Lawndale Christian Health Center in Chicago, Illinois, and I will be joined by other presenters to include Dr. Latoya Furlough, Dr. Tin Long, and Dr. Adrienne Gerzenda. The presenters today have no financial conflicts to disclose. So first, let's just talk through our learning objectives. We really seek to explain so we can understand the epidemiology of Perinatal Mental and Substance Use Disorders and the subset of Vulnerable and Underserved Populations. We want to be able to identify risk and protective factors for Perinatal Mental and Substance Use Disorders in these special populations, and as well as understanding the impact of limited training for mental health practitioners in caring for these populations. So first, I'd like to start with Pregnancy Loss. So Pregnancy Loss, and it's important that we define exactly what we're referring to, is referring to miscarriage, abortion, and fetal death. This is a traumatic event, especially associated with distressing emotions and mental disorders, and often, unfortunately, and often, unfortunately, overlooked in the clinical setting. There are various psychological effects that ensue from Pregnancy Loss, some of which include depressive disorders, anxiety, PTSD, shame and stigma, as well as relationship strain. The mental health effects of Pregnancy Loss often go under-recognized and, as such, untreated. Patients are often left without the necessary resources and support they need to ensure healthy coping. So really, as we're thinking about this, you want to bear in mind that clinicians need to be vigilant for risk factors that may contribute to negative psychiatric and psychological outcomes in this population. It's important to be able to identify persons for whom symptoms become overwhelming, disruptive, and impairing, or an otherwise need of treatment. So let's first think about the impact of Pregnancy Loss. Pregnancy Loss, as it occurs, is associated with an increased odds of certain mental health disorders, including depression, and, as we mentioned, anxiety and PTSD. In a certain study, PTSD was present in 29% of women at one month and 18% at nine months after loss, with moderate to severe anxiety present in 24% of women at one month and 17% nine months after loss, and depression in the same at one month, 11%, and at nine months, 6% after loss. And what this highlights is that the effects of Pregnancy Loss are ongoing. They don't cease immediately after the loss, but it can continue for several months after. In women who've experienced a miscarriage, the prevalence of nine-month moderate to severe PTSD was 16%, and 17% for experiencing anxiety, as well as 5% for depression. It's important to think through the cultural context with regards to Pregnancy Loss. In some cultures, a mother is blamed for a stillbirth, for example, leading to social stigmatization. And it's very common for those who suffer a stillbirth to experience feelings of guilt and shame, compounded by an inability to express their grief over the loss. This, as you can imagine, exacerbates the rates of depression. Many who suffer stillbirth socially isolate themselves, thereby aggravating short and long-term depressive symptoms. So some factors that may increase the likelihood of mental distress following Pregnancy Loss include, but not limited to, of course, prior Pregnancy Loss, which increases the odds of developing depression and other mental health disorders. A lack of paternal support within the relationship dyad is often associated with a four times higher risk of a mother experiencing depression or anxiety following stillbirth. Other factors, of course, include prior psychiatric history, previous relationship strain, no living children, isolation. Miscarriage itself has been associated with greater rates of depression among younger women, women of color, and women from lower socioeconomic backgrounds. For certain populations, the traumatic experience of Pregnancy Loss may be compounded by additional stressors and barriers related to their marginalized status in society. For example, rural dwellers, those from low-income backgrounds, may suffer from reduced accessibility to services. Black women often experience race-related stressors, such as discrimination and bias from healthcare providers, that can hinder their ability to seek or be able to access appropriate care. There is also a lack of grief-related resources for fathers. Healthcare practitioners have a really important role to play when identifying mental health distress following Pregnancy Loss. Firstly, they should be highly vigilant for mental health symptoms following Pregnancy Loss and being mindful of high-risk patients. That means recognizing a patient who may have or carry risks, as we've mentioned before, prior psychiatric history, no living children, maybe from a lower socioeconomic class, but also be mindful of asking with intentionality questions related to the symptoms they're experiencing post-loss. Validated screening tools can easily be integrated into busy clinical scenarios, and in this way, can offer healthcare professionals and practitioners a quick and simple way to determine whether there is need for mental health evaluation. It should be noted that screeners should be used as screeners, and as such should be followed by correct and appropriate connection to care. So, despite the evidence that exists regarding Pregnancy Loss and the mental health effects thereafter, it really remains largely unrecognized and untreated. Some strategies include helping parents process their grief and find healing through bereavement care. Bereavement care is not something that we often see or hear of as being fully and formally developed, but being able to connect parents and families to grief care is often a good first step in helping them manage their pregnancy loss. Facilitating access to community support resources and interpersonal support system and other outlets. Providing education about grief and different grieving styles. It is not uncommon that when patients, both the pregnant person and partner, when patients and families experience a pregnancy loss, they are unaware of what symptoms to even look out for. That guilt and shame, that sadness and depression is something that they are unsure to recognize as either a red flag or something to do something about. So, being able to provide that education as a practitioner at the forefront, you're able to equip your patients and their families and support systems with things to look out for, reasons to reach out for the next level of care or help. Also, encouraging parents to identify and engage in remembrance activities, if desired. Remembrance activities, depending on the type of pregnancy loss, can include a vigil for the lost pregnancy. Sometimes naming ceremonies or celebrations with their family for the life that existed for the time that it did exist can often serve as a moment of closure. Now that we've moved from pregnancy loss, another really vulnerable population are those experiencing intimate partner violence. So, intimate partner violence, or IPV, includes a wide range of violent, abusive, controlling, or aggressive behaviors, such as physical violence, sexual abuse, stalking, emotional abuse, and efforts to control or manipulate a woman's reproductive health. In the U.S., the prevalence rates of IPV during pregnancy range from approximately 9% to 15%, and likely these numbers are underreported. Women with heightened vulnerability for perinatal IPV include younger age women, women of color, those with unintended pregnancies, women from low socioeconomic statuses, single women, and women with low educational attainment. As you can see, running throughout the theme of this webinar series, and certainly this focus topic, is that there is a risk group of population, a population with high risk for increased mental health concerns, and in this IPV world, that risk remains. So, some of the consequences, let's think through, of IPV. So, perinatal IPV is associated, as one can imagine, with adverse mental health outcomes to include substance misuse and substance use disorders, eating disorders, sleep-wake disorders, depression, and obsessive-compulsive disorders, as well as post-traumatic stress disorder. There are other mental health-related outcomes that include low self-esteem, suicidal ideation, and suicide attempts. Women exposed to perinatal IPV have three times the risk of being victim of attempted or completed homicide compared with women who do not experience perinatal IPV. Women exposed to IPV during and after pregnancy may engage in risky behaviors often used as a way to cope with said IPV. These may include using substances such as nicotine or alcohol, missing perinatal care visits because of inability to maybe get away from controlling partners, failing to gain adequate weight during pregnancy, engaging in sexual risk-taking, and poor nutrition. Obstetric and birth complications can include uteroplacental injury, vaginal bleeding, dehydration, miscarriage, stillbirth, preterm birth, and low birth weight just to name a few. The reality is is that the exposure to IPV during and after pregnancy naturally puts the pregnant person and pregnancy itself at significant risk. Despite the prevalence and effects of IPV are well documented, it's not universally screened for as standard of care. The U.S. Preventive Services Task Force recommends screening all vulnerable adults, including women of reproductive age, for IPV. Women who screen positive for IPV need assistance with safety planning, especially those in imminent danger. And this screening piece is essential because without screening and a being able to identify women, we lose an opportunity clinically to intervene as is necessary or as that patient may actually want. So in which ways can we think through this screening and assessment? We can improve our screening practices and remove barriers. In some ways, we can do this by developing clearly articulated written policies and procedures for how screening will take place and what follow-up should be taken for women who screened positive. It is not uncommon that a woman experiencing IPV does not volunteer this information and so therefore as clinical practitioners the onus can be on us to start asking very specific questions. The easiest way to get around asking those questions is to develop these screening policies ahead of time, before that patient gets into your clinical setting. Incorporating where it is possible IPV screening into staff training opportunities about the signs and symptoms of perinatal IPV can go a long way in helping your staff and other clinicians feel equipped in managing and intervening for these patients. Ensuring health care providers receive clinical guidelines and recommendations from federal agencies and women's health experts about the importance of screening and safety planning. As is the case probably with most of what we've talked about throughout this webinar series, being able to prepare and plan in advance of meeting these patients is really helpful to be able to be equipped in the clinical moment. So how do we approach next steps in treatment? We know that women experiencing perinatal IPV have an elevated risk of psychiatric illness and they may need formal psychiatric treatment or psychological counseling. Being able to identify who these women are puts us in a better situation and position to connect them to much needed resources. Clinicians should therefore offer patient-centered, tailored, multi-component interventions that involve education about IPV and its effects, safety planning, and instrumental support. Treatment for women experiencing perinatal IPV should take a trauma-informed approach. It must ensure a woman's safety, confidentiality, and privacy. Trauma-informed CBT and standard CBT have demonstrated effectiveness among women experiencing IPV. Being able to be aware of what resources in your community or within your network are available to offer such approaches is imperative to be able to connect women to the necessary resources. I'd now like to hand it over to Dr. Latoya Frolov to take us through the rest of our special populations. Hello, everyone. My name is Dr. Latoya Frolov and I'm an assistant professor of psychiatry at UT Southwestern and adjunct professor at Weill Cornell. I'm a child and perinatal psychiatrist and I'm excited to be able to talk about our next population, adolescents. So the U.S. continues to have the highest teen birth rate among industrialized populations, nations, despite this trend actually decreasing over the last several decades. We know that over 10% of infants born to adolescent mothers may be premature and that birth defects may disproportionately affect children of very young mothers who may be less likely to take folic acid. Adolescent mothers are at high risk of adverse pregnancy outcomes, such as preterm delivery and low birth weight. Risk factors associated with adolescent pregnancy include being among racial, ethnic, and or sexual or gender minority groups, coming from a household that has low socioeconomic status, any history of and or current homelessness, involvement with welfare or the justice system, prior or current substance use, history of running away, cognitive delay or learning disabilities, parents being divorced, separated, or having an absentee father, and exposure to an incarcerated family member. So adolescent mothers report high levels of comorbid traumatic experiences, including sexual abuse, intimate partner violence, physical violence, emotional adversity, loss of a caregiver or sibling, and community violence or urban social stress. So there are high rates of intimate partner violence among adolescents who are pregnant or parenting. And adolescent mothers report higher levels of perpetrating the intimate partner violence, including perpetrating psychological abuse and or physical conflict than being the victim of it. And risk factors for perpetrating physical assault include perceived partner infidelity, attachment anxiety, prior assault by a partner, exposure to community violence, being in trouble with the police, and multiple lifetime drug use. Intimate partner violence experienced by adolescent mothers during the perinatal period is associated with many adverse health outcomes during the infant's first year of life, including lower birth weight and preterm birth, child maltreatment, poor or fair nutrition, lack of regular primary healthcare practitioner visits for the parent, and missing regular well child checkups for their child, and lagging on childhood immunizations. Justice-involved youth who intend to become pregnant or have a positive attitude toward future pregnancy are more likely to exhibit symptoms including depression, hyperactivity, impaired self-control and self-esteem, and symptoms related to trauma. And there may also be differences in pregnancy rates among youth that are court-involved versus incarcerated. So almost 13% of court-involved juveniles reported a current or prior pregnancy compared to over 30% of detained or incarcerated juvenile offenders. Sexual and gender minority youth are more likely to exhibit sexually risky behaviors and to experience or be involved in an adolescent pregnancy. And there are disparities in teen hormonal contraception youth in pregnancy that have persisted despite the general rates, as I mentioned, of teen pregnancy declining over the past several decades. Enriched training for medical and mental health clinicians is necessary to provide a skilled workforce for sexual and gender minority adolescents. Adolescent mothers and their children are at high risk for depression and associated negative educational, social, health, and economic outcomes. Adolescent mothers face unique challenges including fear, difficulty transitioning to being a teen mother, feelings of being overwhelmed and confused, low self-esteem, rejection by peers, a sense of abandonment and isolation, and concerns about derailment of their educational aspirations. They may put them at higher risk than parental stress and depression. So the incidence of postpartum depression among adolescents ages 15 to 19 is double the rate of mothers older than 25 years old. Adolescents with perinatal depression are at increased risk of substance use, birth complications, and impaired parenting ability with poor mother and child interactions. Adolescent mothers with postpartum depression may be three times more likely to attempt suicide than antenatal adolescents or adolescents that are pregnant. Substance use among adolescents is a risk factor for unplanned pregnancy and subsequent fetal exposure. Three in five pregnant teens in the U.S. report substance use within the previous 12 months. Adolescent mothers have reported higher levels of personal or peer substance use before pregnancy compared to other adolescents. They are more likely to meet criteria for substance use disorders including alcohol, cannabis, stimulants, and opioids. Some adolescent mothers continue using substances while pregnant, but most report attenuated use over the course of pregnancy and then resume within six months after giving birth. So factors such as exposure to caregiver alcohol use, excuse me, peer alcohol use and drinking as a coping mechanism may be associated with a higher risk for moderate to heavy drinking during the perinatal period. And substances used may vary by race and ethnicity. One study found that white adolescent mothers are more likely to smoke cigarettes and use cannabis, whereas black adolescent mothers may be more likely to drink alcohol and use other drugs. And there's an overall dearth of studies on Hispanic adolescent mother substance use. Alcohol and illicit drug use are associated with depression among adolescent mothers in the antenatal and postpartum periods. Pregnant adolescents with parental support and engagement in school are significantly less likely to use substances. And adolescents with substance use in addition to bipolar disorder had significantly higher rates of pregnancy and abortion over the past 12 months compared to those without. So let's talk about treatment interventions. Because we know that inaccessibility, lack of awareness of perinatal mental health programs, and poor mental health literacy have been identified as barriers to engagement and treatment. So preventative behavioral interventions may include home visits, cognitive behavioral therapy, interpersonal therapy and other psychoeducational interventions. Next, I'm going to talk about the incarcerated population. So let's talk about the numbers. So women represent a growing percentage of the US prison population, with approximately 150,000 women incarcerated in 2020, a 475% increase since 1980. Over half of the women in prison report having children under the age of 18. And over 1000 infants are born to women in prison each year. Incarcerated pregnant women are largely from minority groups with low pre incarceration rates of access to health care, and higher rates of substance use, trauma, and poverty. Low rates of screening are reported for perinatal mood and anxiety disorders in the incarcerated pregnant population. So up to 80% of pregnant women currently or recently incarcerated have reported high levels of perinatal anxiety, depression and substance use, particularly alcohol and tobacco. Incarcerated mothers have reported high rates of depression, substance use and symptoms associated with thought disorders. One third of incarcerated women who gave birth in custody reported moderate to severe depressive symptoms following delivery, with higher rates among women with longer periods of separation from their infants due to the longer sentences following delivery. Let's focus on substance use disorders. Illicit drug use is reported by up to 36% of incarcerated pregnant women. Only 40% of incarcerated women with opioid use disorder during pregnancy received appropriate treatment, and less than a third were referred to a community practitioner to continue treatment on release. Jails and prisons require license to operate as health care facilities to provide evidence based medication assisted treatment or MAT. There is significant variability in screening for opioid use disorders and provision of this treatment for incarcerated pregnant women who enter the jail during treatment or initiated for opioid withdrawal. So what gets in the way of treatment? Societal attitudes including stigma and distrust can impact the treatment of incarcerated pregnant women who may receive inconsistent treatment by both health care professionals and prison workers. Restraints in the form of handcuffs, belly chains and leg shackles may endanger the life or the health of mother and child, but they are still routinely used. Recommended nutrition, adequate rest and attention to comfort such as having a lower bunk, double mattress and female identifying correction officer are not guaranteed. How does incarceration impact parenting? So that the negative impact of incarceration on the mother baby dyad and parenting is well documented. Upon incarceration, children are often placed with maternal relatives or in the foster care system. For those with subsequent criminal justice involvement, the majority retain legal custody, and only felony arrest is a significant predictor of foster care involvement. Incarcerated mothers have reported feelings of guilt, shame, inadequacy and incompetence as a parent that is compounded by hardship in providing for their children. The impact on attachment may be exacerbated by the incarcerated parents own experience of separation from their caregiver as a child and insecure attachment. Barriers such as distance, variability and visitation and contact policies and caregivers of the children may pose significant barriers to parenting while incarcerated. Stressors related to parenting have been associated with greater difficulty adjusting to the prison environment and misconduct. Infants of incarcerated women are significantly less likely to be fed breast milk and have longer unadjusted lengths of stay following delivery. So what do we recommend? The impact of forced separation due to incarceration on early attachment has been in part mitigated by the implementation of prison nurseries and correctional facilities. Children who co-reside in prison nursery units during their first 18 months of life have significantly lower levels of anxiety and depression in preschool compared to children who lived with an alternate caregiver. Out-of-prison nursery programs in which an incarcerated pregnant woman is transferred during her last trimester can increase mother-infant bonding. Enhanced pregnancy services such as doula support have been proposed to improve maternal and neonatal outcomes among incarcerated pregnant women. Women who received evidence-based lactation support in prison in the prenatal period from doulas were significantly more likely to initiate breastfeeding. Supplemental nutrition, work modifications, and encouragement to engage in prenatal health care services are recommended. Job training, educational support, substance abuse programs, and parenting classes can positively impact future reunification with children and reintegration into the community. Thank you. So we're going to have our next presenter present on immigrants and refugees. Hi, I'm Tin Luong, and I'm a UCLA Health Sciences Clinical Assistant Professor in Psychiatry. I also run the All of You Medical Center Reproductive Mental Health Consult Service. Today, I'll be talking about immigrants and refugees in perinatal mental health. About a third of migrant women from low to middle income countries are estimated to have perinatal depression. Women with asylum seeker and refugee status often have worse perinatal mental health and obstetrical outcomes. These outcomes can differ based on where they're from, which country they end up in, health care access, immigration status, length of residence, political context, legal status, stress, and other factors. What is clear is a need for perinatal care and social support that is individualized and culturally sensitive. During pre-migration and migration, trauma, including sexual or gender-based violence, can increase the risk of PTSD. In certain groups, including children, sexual and gender minorities, and women may be placed in vulnerable situations and at risk for more systematic violence and discrimination. Pregnant immigrants may also endure physical demands that can be dangerous for their physical health and also mental health, including travel on cargo freight trains, crowded boats, unsafe walks before arriving at their destination. In places like refugee camps and detention and en route to their destination, reproductive health can also be compromised by decreased access to perinatal care, also decreased access to contraceptives, increased exposure to unsanitary conditions, and risk of infectious diseases. In resettlement, there can be acculturation stresses that can affect mental health during the perinatal and postpartum periods. There can be feelings of optimism, but also grief over loss of cultural norms, traditional roles, and supports. There can be difficulty coping with separation from family, non-optimal working conditions, inequitable pay, discrimination. And again, health outcomes can depend on the degree of acculturation in the host country. A favorable trend that's been noted in many studies is that perinatal substance use, for example, smoking and alcohol use, seems to be less common in most immigrant groups compared to US-born counterparts. About 20% to 45% of immigrant mothers are diagnosed with substance use disorder. And about 50% of immigrant mothers are diagnosed with postpartum depression after arriving in the host country. This can be affected by duration of stay, socioeconomic factors, health status, social support, including which host country they're arriving at. The reporting of postpartum depression symptoms can also be affected by traditional gender cultural beliefs, societal expectations of what parenthood should be like, stigma, limited awareness of postpartum depression, language barriers, and legal status stress. There, postpartum depression can also be impacted by the absence of desired postpartum traditions and ritual support system. Individualized, compassionate, culturally sensitive care can help offset feelings of isolation and lack of control during the birthing process and managing the postpartum period in an unfamiliar system. Because inadequate language proficiency has been associated with isolation, lower self-esteem, lack of access, and possibly higher prevalence of mental illness, proper translation is essential to providing optimal care. In the literature, culturally competent social support includes employing doulas familiar with cultural and linguistic needs of patients, multidisciplinary teams that might include health care practitioners, also non-behavioral health practitioners, translators, community advocates, public health advocates, and inclusive public policy. With therapy, culturally competent social support can also include being mindful of the impact of immigration stresses in addition to the person's identity outside of being an immigrant. Recommended medical screenings for immigrants and refugees include infectious diseases, vaccinations, nutritional deficits, as well as screening for exposure to environmental changes. In addition to screening for environmental toxins like lead, medical screening can also include gender screening for gender-based violence. Screening for female genital cutting is warranted as it can provoke anxiety during delivery, feelings of shame, lead to reactivation of trauma, and can have obstetrical repercussions. Although female genital mutilation can occur worldwide. Mental health screening for immigrants and refugees includes attention to cultural differences in presentation and expression of psychiatric symptoms and disorders. So sometimes expressions of anxiety and depression may be in the form of somatic symptoms. Some appropriate screening tools include Refugee Health Screener, otherwise known as RHS-15, and PHQ-9, which have been internally validated and translated into several languages. Legal status and public policy surrounding immigration can also have implications for access to prenatal care, especially for undocumented immigrants. More restrictive immigration policies and fear of deportation has been associated with increased perinatal anxiety and also associated with an increase in preterm births, particularly in some groups, such as Black mothers born outside the US. Medical care can also be compromised due to foregoing of social services and fear of penalties to immigration status. Legal status can also have impacts on the experience parents have with their children. And this can then impact the mental health of children also. To end with, there are disparities in access to care in timely perinatal care. Mental health care is underutilized, as well as social service and welfare programs, especially in undocumented immigrants. The next section will be on infertility and mental health. Depression, anxiety, and emotional distress are prevalent in patients dealing with infertility. A substantial number of patients undergoing infertility treatment are diagnosed with a psychiatric disorder or have an acute depressive disorder or have an acute depressive disorder during treatment. Feelings of anger, shame, stigma, loneliness can take place. There can be relationship strains and trauma, especially when there is pregnancy loss. So these risks necessitate greater mental health support, screening, and access to care for patients dealing with infertility. In addition, fertility drugs can have impact on mood. Patients can be more susceptible to mood fluctuations and emotional distress during assisted reproductive technology procedures. And thus, it's common for patients who are experiencing infertility, undergoing IVF, in vitro fertilization treatment, or have difficulty maintaining a pregnancy to report poor quality of life. Trauma symptoms can be exacerbated during infertility treatment, especially when there's pregnancy loss or unsuccessful IVF. Emotional support and counseling can be protective during these experiences, which can lead to grief and regret. It's important to understand that there are different types of trauma. There is also a significant percentage of infertile population, but more research is needed to understand what they're going through and also the psychiatric impact of male infertility on their partner's mental health. So while it's clear that infertility can cause stress, evidence of whether stress can cause infertility is not clear. Whether stress can cause infertility is not definitive. Proposed mechanisms include physiological changes associated with the depressed and stressed state, such as abnormalities in the HBA axis, elevated prolactin levels, and thyroid dysfunction. There's also not a clear understanding of whether psychiatric illness affects infertility. In a secondary analysis from randomized trials, women with infertility who had male partners with active major depressive disorder experienced decreased pregnancy rates. In another study, they investigated the relationship between PTSD and time to conception, but that was not conclusive. Termination of IVF treatment can also be due to emotional problems and financial costs. Cancer is a specific stressor that can compound psychiatric effects of infertility. Patients with cancer often face infertility and can experience problems accessing psychiatric services, even though it's a population that commonly reports depressive and anxiety symptoms. It can be a stressful time where there's time-sensitive decisions about whether to pursue fertility preservation. Additional burdens that can factor in could be high costs of fertility preservation and also lack of insurance coverage for these procedures. So counseling with a mental health provider is recommended and may help increase life satisfaction, decrease emotional distress, and improve coping. Decrease emotional distress and improve coping with the decision-making process, which can be difficult. Often mental health problems can be detected while evaluating the cause of infertility. And infertility specialists, while they believe that mental health conditions can negatively impact reproductive outcomes, many report that they may not be screening for psychological disorders in women with infertility. And the reasons include lack of time, unfamiliar with mental health treatment recommendations. Screening for substance use disorders in people undergoing fertility treatment is important because substance exposure can impact the success of infertility treatment and also the patient's mental health. Alcohol is not recommended before infertility treatment and during pregnancy, given the increased risk of birth defects and fetal loss. Smoking tobacco, there's compelling evidence that it adversely affects IVF outcomes, including some of these parameters listed, such as life births per cycle, pregnancy rate, retrieved oocytes, average fertilization rate, increased miscarriage rates. Adverse obstetrical outcomes are noted in pregnancy with cannabis use. And there is also potentially prolonged fetal exposure to cannabis that's stored in tissue. So cannabis should be avoided. Opiate use, there has been associated increased risks of pregnancy loss. So that should be avoided as well, if possible. Meeting mental health needs in infertility involves optimization of psychotherapy and psychopharmacology. Psychopharmacology is discussed in more detail in other parts of the webinar, but it's important to keep in mind that antipsychotics have the potential of inducing hyperprolactamemia, which can lead to amenorrhea and menstrual cycle disruptions by affecting the HPG axis. There's limited data that suggests adverse effects of some psychotropic, some sperm parameters, such as quantity and mobility. And we can't ignore that there's a risk for the exacerbation of mental illness by stopping psychotropic medications that can lead then to patients dropping out of infertility treatment. Patients can get some relief from their emotions, the stress, even if they're not in a state of their emotions of stress, even with brief contact with their physician, especially after important steps like embryo transfer. And feedback from clinical practitioners suggests that areas of improvements that can be made in communication with the patient include discussing the uncertainty of treatment success, treatment duration, and costs. Further research is needed, but there have been studies to show some benefit of mind-body and complementary interventions such as music therapy, yoga, and acupuncture, but further rigorous research is needed. There are some benefits also of psychological interventions and emotional support is important in individuals struggling with infertility. These benefits can be improvements with depressive and anxiety symptoms, infertility stress, and relationship strains. And some studies show an association with improvement rates of conception of women going through infertility for those who receive psychological interventions, but this requires further research. So it's also been just suggested that the integration of mental health support from clinical practitioners into infertility treatment teams can be helpful in decreasing psychological distress during infertility treatment. And so to end with, there are disparities and ethical situations that it's important to keep in mind. Those who pursue and have access to infertility treatment generally report better life satisfaction and self-esteem than those who did not seek treatment or are unable to. These disparities can depend on socioeconomic, educational, cultural, and demographic factors. There are also ethical situations regarding infertility treatment, such as high order, multiple births, egg banking, third-party reproduction, and mental health repercussions that come along with infertility treatment. Thank you. I'm going to hand it over to the next speaker, Dr. Grazenda. Good morning. My name is Dr. Adrian Grazenda. I'm a clinical assistant professor of psychiatry at UCLA and UCLA Olive View Medical Center. Today, I'll be discussing sexual and gender minority individuals and their pregnancy considerations. For the purposes of this talk, we will be referring to people as sexual or gender minorities, which is the standard NIH, NIMH verbiage, rather than sort of the acronym that people are more familiar with, which is LGBTQIA, Two Spirits, et cetera. So an important consideration that is often a very popular misconception among healthcare providers and potentially also mental healthcare providers is that individuals who identify as a sexual or gender minority do not intend to start families or become pregnant, which is a very, very common misconception. And lifetime pregnancy is totally common amongst sexual and gender minorities. A study of post-menopausal, cisgender, sexual minority women revealed that approximately 35%, so those who were self-identified as lesbians and approximately 81% of those who self-identified as bisexuals reported at least one prior lifetime pregnancy. Among those individuals who are assigned female at birth, gender minority adults, regardless of whether they identify as transgender or non-binary, had reported previous pregnancies ranging in rates from 12% to 17% lifetime. The perinatal period for sexual and gender minority individuals can involve a lot of increased stress, a lot of complexity, a lot of unique mental health challenges because of the intersection between personal gender and minority identity status, potentially biological changes, which we'll discuss more later, as well as psychosocial changes. So sexual and gender minority individuals have consistently higher adolescent and unintended pregnancy rates compared to their heterosexual or cisgender counterparts, specifically girls identifying as lesbian, bisexual, or questioning also have significantly higher odds of not using contraception compared to their heterosexual peers. In general, the trend for teenage pregnancy has been going down, but in this group, there is still the potential for high rates of unintended pregnancy, particularly in the adolescent group, which was discussed earlier in the adolescent presentation. Bisexual adolescents aged 15 to 21 have more than a three times higher likelihood of seeking pregnancy termination, according to data from the National Survey of Family Growth. Additionally, in a study of gender minority adolescents, approximately 26% had experienced some form of an unintended pregnancy, which is more than twice the rate of their cisgender peers, even though the rates of contraception were close to that of the national average of around 62%. There's a lot of misconceptions, so to account for that seeming discrepancy between contraceptive use and unintended pregnancy in gender minority adolescents, there can sometimes be misconceptions about the impact of testosterone or other gender-affirming treatments on one's reproductive ability, which tends to be a risk factor for these unintended pregnancies. In general, in a study of gender minority adults, 54% of their previous pregnancies were unintentional, so this is sort of a rate that continues from adolescence into adulthood for many of the same risk factors, so again, a lot of misconceptions about the role or impact of gender-affirming treatments on ability to become pregnant. In a survey of gender minority adults, approximately 19% had tried to terminate their pregnancy without clinical supervision, so very risky sort of situation using methods such as physical trauma or substance abuse, highly concerning. Reasons that they cited when asked were privacy concerns, prior maltreatment from healthcare professionals regarding their gender minority status, and cost. Now, generally, sexual and gender minority individuals as a historical trend have about approximately a two-times more likelihood of experiencing depression, anxiety, trauma, and substance misuse compared to their cisgender heterosexual peers. This is a trend that we additionally see in the perinatal mental health period for this subgroup, where over a third, so about 35.6% of sexual minority women, reported experiencing clinical depression, which is a much higher rate than we see in sort of the overall population for childbearing individuals, with an average rate there of measured at about 10% to 20%. Sexual minority women have also reported more engagement in substance abuse during the perinatal period, including binge drinking, smoking, and cannabis use, compared to heterosexual counterparts. Don't know a whole lot about some of these patterns in gender minority individuals in the perinatal period, primarily because of historical exclusion in research, and we expect that it's probably on par with those of sexual minority women or potentially higher. But again, this is a gap in research. Unfortunately, we don't have precise rates. So there are a lot of factors for sexual and gender minority individuals that can impact mental health, and especially perinatal mental health. It can be psychological, it can be social, healthcare access-related, biological factors, especially for gender minority individuals who may be undergoing transition. Certainly, there's the minority stress model that is in play, where the intersection of internalizing and externalizing forces of stigma, prejudice, discrimination, internalized transphobia, internalized homophobia can be a common psychological risk factor that can potentially be amplified during pregnancy. Obviously, the perinatal period comes with its own stresses, regardless of sexual and gender minority status, but that can intensify. Certainly during the perinatal period, pregnancy itself for the individual can sometimes come into conflict with that individual's personal gender identity or their sense of gender role of themselves or within the relationship, and that can potentially be increased in healthcare interactions. Most healthcare settings tend to be very heteronormative, so the individual may kind of sort of come in constant conflict between their personal identity and the care that they are receiving if the care is not appropriately delivered. Sexual and gender minority women face barriers to motherhood. Specifically, this was from a study of lesbian-identified mothers. It was a qualitative study that found that there were logistical issues just in terms of financing, balancing employment versus motherhood, unsupportive laws, and in general, societal discrimination that impacted them during the perinatal period. Now, positive social support can be a buffer against poor mental health, and obviously isolation, discrimination, stigma can increase risk. The same study that I was just mentioning, those lesbian mothers with postpartum depression also reported feelings of invisibility and social rejection, and again, as I mentioned, heterosexism from healthcare practitioners is very common. Certainly mental health practitioners are also not excluded from this potentially, again, by sort of that simple misconception of, you know, how gender and sexual minority adolescents or adults approach their sort of reproductive health and family planning. Non-gestational parents are often very overlooked in research, and they, too, may experience perinatal distress due to a lack of sort of biological role in the pregnancy, lack of legal protections, lack of legal involvement in relation to the infant, potentially few role models as it is a very small community, and potentially limited social support either from, you know, societal rejection, as mentioned previously, or feeling lack of support within the partnership with the gestational parents. Sexual and gender minority individuals face healthcare disparities, as is widely known, including discrimination, lack of culturally competent care, and denial of services, and that can certainly be amplified during perinatal mental health. For masculine identified sexual minority women and assigned female and birth gender minority persons, pregnancy can certainly create a conflict due to its very gendered nature. Obviously, in some cases, there may be a requirement for cessation of gender affirmation hormones in order to facilitate the pregnancy and exposure to fertility treatments, which can really exacerbate gender dysphoria for the period at which point the pregnancy is occurring. Certainly, gender minorities can face discrimination, harassment, and violence simply due to potentially discrepancy between their physical, you know, their gender expression and identity versus the typical patient in a, you know, pregnant…in a women's healthcare clinic, such as facial hair and things like that, a deeper voice, which can cause a lot of issues. Additionally, there are simply mechanical issues potentially as well, such as the use of breast binders, which can hinder lactation and increase risk for mastitis, infection among gender minority individuals, all to be considered and potentially can impact mental health. Now, important to mention, not covered, you know, very significantly in the toolkit, or rather in the white paper that the APA has provided, is the role of assigned male at birth sexual gender minority individuals and couples. Certainly, they are also at heightened risk for mental distress. Those who intend to start families either via adoption or surrogacy, gay male parents report a need for social acceptance, also similar to lesbian mothers experiencing a lot of perceived social rejection, as well as heightened internalized homophobia along in that minority stress model during the point of family planning. Successful parenting outcomes among gay adoptive fathers, again, much like their other counterparts within sexual gender minorities, subgroups really facilitated by and buffered by social support, positive identity, affirming identities. Failed adoption and surrogacy matches have been found to be amongst prospective sexual gender minority parents, leading to a grief and a bereavement, very similar to pregnancy loss. It's important not to forget these individuals when thinking about perinatal mental health. There is very limited and mixed evidence on the association between sexual and gender minority status and perinatal obstetrical and neonatal outcomes. A number of studies have found, you know, there may be an association between same-sex parents, decreased fetal growth and preterm birth, but at least one study found that there was really no, you know, there was a very similar rate between the two. This is obviously largely confounded by the use of assisted reproductive technologies in both groups, so hard to make a determination there, but most likely no difference. Gender minority patients, parents rather, in any partnership type really, at least in the one study that has been done, did not face any significantly higher risks of adverse obstetrical or birth outcomes. And really, the biggest concern in regards to perinatal outcomes is this high rate of unintended pregnancies, as we know, regardless of sexual gender minority status, that unintended pregnancies are universally associated with poor pregnancy outcomes. But the connection between pregnancy intention, outcomes, just sexual and gender minority status, and any type of perinatal obstetrical and neonatal outcome is, in general, undersearched, under-researched. So for the most part, these are N of one, perhaps two or three studies, so very hard to make sort of a consensus determination. In general, the APA and other groups support this of using an affirming care model. Healthcare practitioners are really the center of that as the critical liaison, the critical sort of standards center in terms of making the transition to parenthood easier for sexual and gender minority patients. That inclusive healthcare model should incorporate, obviously, cultural sensitivity, respect for privacy, and personal autonomy. The communication between various disciplines can also really help achieve an integrative approach that brings together all of these aspects of care, where care is coordinated and the individual feels affirmed throughout the process. And certainly, it is important for every practitioner within a healthcare setting to have a firm understanding of the unique experiences, challenges, and health disparities that are faced by the sexual and gender minority community, and really critical to improving outcomes and assuring good outcomes in this population. Obviously, there's a lot of education and training gaps among gender regarding sexual and gender minority health, in particular, among perinatal mental health in this population. There needs to be more ongoing professional education, training, and personal reflection onto the types of biases and stereotypes in order to help clinicians understand their own personal biases and how to correct those in order to really provide an affirming model for sexual and gender minorities, not only in regards to their reproductive health, but their reproductive mental health. There's often a reported lack of knowledge amongst practitioners regarding gender minority reproductive health options and factors, such as the effect of cross-sex hormones on fertility in gender minority individuals. Obviously, practitioner education can help alleviate some of those fears. It can also help alleviate fears of simply causing offense by using wrong pronouns or more heteronormative language, understanding how to make those adjustments to allay feelings of inadequacy, to allay fears of making missteps, which can help strengthen the relationship between the practitioner and the patient to avoid the distrust and aversion to healthcare that can sometimes occur, such that sexual and gender minority individuals feel comfortable throughout the perinatal period to seek assistance if needed. There's really a need for effective contraception counseling. Obviously, as we have reviewed here sort of repeatedly, unintended pregnancy is very common, and we know unintended pregnancy comes with sometimes negative outcomes for mental health for the individual, physical and obstetrical poor outcomes as well sometimes. Really, this starts at the point of prevention. This is the responsibility of every practitioner, whether a medical practitioner or mental health practitioner. We're all able to address contraception issues. Hopefully, also increased learning is to understand options for patients that may help minimize gender dysphoria or discomfort, certainly if they're not a gender minority individual but simply have a gender identity that may find discomfort with the pregnancy process of understanding how to support that individual from the point of planning for a pregnancy through the pregnancy and beyond. Finally, this is just a reiteration that the APA recommends comprehensive screening for mental health issues during the perinatal period, regardless of gender and minority status. For sexual and gender minority individuals, there certainly should be consideration for additional screening, given we know there are high rates of trauma, high rates of experienced stigma and discrimination, all of which can contribute to mental health issues during this period. Finally, there are no specific interventions that are evidenced to the point of, say, randomized controlled trials in the sexual and gender minority population. This is a huge gap of our understanding for this population. We certainly know that other evidence-based theories, psychosocial, psychotherapy modalities that have been evidenced can be adapted to the sexual and gender minority population during the perinatal period, such as cognitive behavioral health to address identity issues. Acceptance and commitment therapy can help those dealing with internalized stigma, difficulties relating to identity as well. Certainly interpersonal psychotherapy can be effective, especially for those with social isolation and, again, difficulties in relation to pregnancy in relation to their gender or sexual identity. Psychoeducation plays an enormous role as an intervention, both for the individual but also for the individual's social support network, as we've indicated here, regardless of sexual, gender, minority identity type. Social support is a huge resilience and mitigating factor for worsening of mental health issues or emergence of new symptoms and can really help bolster individuals throughout the pregnancy and beyond. Certainly educating the individuals themselves about what to look for, but also their support network, whether that is the non-gestational partner, whether that is family who may have similar misconceptions about family structure, family planning, pregnancy in those individuals who are gender or sexual minorities, allaying some of those misconceptions and really enforcing that these individuals simply need support can play an enormous role in helping improve outcomes. In conclusion, in order to provide the highest standard of care for sexual and gender minority individuals during the perinatal period, it entails not only treating the mental health symptoms, but also addressing underlying factors that contribute or exacerbate these symptoms, such as stigma, discrimination, and social isolation. Overall, as we've seen in this section regarding vulnerable populations, undisturbed populations, or topics of special consideration, a one-size-fit-all approach to the mental health of pregnant and postpartum individuals is not evidence-based care. It does require special consideration of the unique facets of these individuals in order to provide the best care. Certain populations have additional vulnerabilities and risk factors for exacerbation or development of new symptoms, new mental health or substance use disorder symptoms that have to be considered. More than anything, the provider needs to be aware, and certainly culturally-competitive care is necessary in order to facilitate engagement and improve outcomes for parents and their offspring. Thank you. It is our pleasure to acknowledge the many people who have contributed to this webinar and to the APA and CDC Foundation project it represents. This includes the APA research team and the principal investigator of this project, Dr. Diana Clark, as well as the CDC Foundation team, our science writer, and the panel members of the physician and non-physician behavioral health advisory panel drawn from the disciplines of psychiatry, psychology, counseling, nursing, and social work. Those of you who would like to learn more about this initiative can go to this website, www.psychiatry.org, backslash maternal, hashtag section four. In addition, for those of you who wish to see the references cited in this webinar series, those are listed in the following slides. Thank you.

perinatal mental health

substance use disorders

psychiatric treatment

best practices

inclusive language

perinatal period

inadequate training

pregnancy loss

intimate partner violence

mental health disparities